PASTORAL CARE
IN THE LTC SETTING
Just as Death Is Part of Life, Spiritual Care Should Be
Part of Long-Term Care
BY KARIN "TEDDI"
TOMSIC
/ /
Ms. Tomsic is
director, Pastoral
Care and Mission,
St. Joseph's Manor,
Trumbull, CT.
N
"^^k
"^P^ursing homes," 1 once heard
it said, "are built on a mountain of unexpressed grief.'
The speaker was referring
not only to the grief of a res
idem facing debilitation .md death but also to the
grief of the resident's family and professional
caregivers. The speaker went on to describe the
psychological walls that people build to protect
themselves in such an atmosphere. Staff turnover,
difficulties in hiring and assimilating new employ
ees, troubled relationships between staff members
and residents and their families—all such problems are at least partly caused by unexpressed
grief.
It is easy to understand the grief of residents
and their families. Most people enter long-term
care because of debilitating illness or injury.
Frequently such people have outlived a spouse or
family caregiver ,\nd are now losing home, routine, and everything familiar. Their family members often feel guilty about placing their loved
one in a long-term care (LTC) facility. That guilt
is sometimes expressed as anger and dissatisfaction, which cm cause friction with both their
loved one md the staff. Meanwhile all involved
ask themselves, "Why is this happening:" "What
docs this mean?" and "Will this happen to me?"
STAFF GRIEF
Our institution, St. Joseph's Manor, is a 297-bed
LTC facility in T r u m b u l l , CT. I direct the
Pastoral Care Department, which is composed of
four certified chaplains, one appointed priest
chaplain, and one pastoral assistant.
When I fust began working in long-term care,
I was struck by the complete dominance of the
medical model. It seemed to me that the "nursing" part of the phrase unrsinji home had completely overshadowed the comfort implied by
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MARCH - APRIL 2 0 0 2
"home." I later came to realize that the medical
model reigns in long term care because people
with medical backgrounds dominate the LTC
regulatory process. Current regulations, rooted
as they are in the concept of self-determination,
are meant to help caregivers formulate care plans
according to resident values and goals. Of course
self-determination involves risk; self-determining
elderly people sometimes fall and hurt themselves. Vet those who do the regulating question
the resident's every tall, every pound of weight
lost, and every decline in his or her health status.
In such an atmosphere, it is understandable
that acute care methods have gradually become
accepted as proper care for the chronically ill and
aged. LTC professionals, who work very hard to
care for their residents, sometimes feel overwhelmed MK\ discouraged by a system that continually criticizes their efforts. Because peopletoday live longer than they used to, society contains more people suffering incurable, progressive, and eventually fatal illnesses.1 It is thus no
wonder that grief is so common.
PROFESSIONAL PASTORAL CARE
One way LTC leaders can begin to address this
situation is by adding staff members trained to
deal with grief in all its varied forms, namely certified pastoral chaplains. Health care chaplains arc
generally certified by one of several bodies, for
example the National Association of Catholic
Chaplains (NACC). NACC certification is based
on professionally determined criteria designed to
produce competent, qualified chaplains.
The criteria are:
• Theological training (usually an advanced
degree)
• Four units (a unit is 400 hours) of clinical
pastoral education (CPE)
• Endorsement by a faith community
HEALTH PROGRESS
• Certification by the commissioning body
CPE combines pastoral theology and psychology. After completing it, a candidate tor certification in NACC submits documentation of his oilier compliance with 30 standards addressing per
sonal, theological, and professional competencies. The NACC reviews these documents and
then schedules an interview for the candidate with
a certification team of three examiners. Following
the interview, the team forwards its recommendation to a seven-person certification commission.
Although the commission often accepts the
team's recommendation, it is not bound to do so.
Every five years, to maintain their status, certified chaplains submit documentation of 150 hours
of continuing education and are quizzed by a peer
reviewer on their skill in applying what they have
learned. These actions, which ensure the chaplain's
competence and ability, are important because the
certifying body shares in the chaplain's liability,
according to Michcle LeDoux Sakurai, a former
NAAC official. "Many healthcare administrators
are unaware that they are liable for the actions of
visiting clergy," Sakurai said in a telephone conversation. "But a certified director of pastoral care has
the training and background to observe other ministers coming in to provide pastoral support and to
assess their competency to 'do no harm."'
Most chaplains also receive some training in
ethics. Some people view the ethical issues that
arise in long-term care as less dramatic than those
in acute care, but LTC issues are equally challenging to discern. Professional chaplains have much
to offer in helping residents, their families, and
other LTC staff.
PASTORAL CARE AND NURSING
The impact of any health care service is usually
measured according to the perceptions of those
who are affected by the service. Medical and
nursing start" tend to see the benefits of pastoral
care most clearly in end-ol-life situations. In my
experience, most health care professionals are
instinctive caregivers. Although the disciplines
they train in vary, such people generally want to
"do something" to make things better for others.
As a result, they often feel extremelv helpless
when they see that a patient is dying.
Death often causes health care professionals to
note the importance of the chaplain staff, whom
they see keeping vigil with the resident and his or
her family. "Especially at the time of death, the
nurses recognize the support of pastoral care."
Alice Mondi and Cecilia Roberge, our director
and assistant director of nursing, respectively,
HEALTH PROGRESS
recently told me. Mondi went on to say:
They often feel that someone needs to beat the bedside, and because they are so
busy doing other things, knowing that you
are sitting there helps them not t o feel
guilty. If nurses want to be with the resident and can't be, it seems to them to leave
a void; pastoral care fills that void. . . .
Because nurses are very task oriented, they
find it difficult to understand the more
" n e b u l o u s " nature of pastoral care.
However, nurses want to feel that they did
all they could, even when that can't "fix"
it. The presence of pastoral care staff
enables nurses to become more comfort
able with and adept at the practice of palliative care and pain management.
Health care professionals' perception of pastoral care staff as "sitting and praying" is accurate.
but it fails to note the work they do before a
death vigil begins. Chaplains are often the LTC
staff members to whom residents convey their
hopes and values. From admission onward, a
trained chaplain encourages residents to express
their feelings, both negative MK\ positive.' This
procedure allows the chaplain to measure residents 1 emotional and spiritual well-being. Evert
those residents who have lost the ability to speak
clearly can, through gestures and simple responses, demonstrate what they consider meaningful.
LTC facilities should consult their residents'
wishes when drawing up care plans. Unfortunately, doing so requires giving residents the
time to express their wishes —time that nurses
often do not have to give. Chaplains, however, do
ST. JOSEPH'S MANOR IS HONORED
In July 2001 St. Joseph's Manor was named the winner of the second
annual Circle of Life Award, honoring the facility's innovations in end-oflife care. The award is cosponsored by the American Medical Association, the American Hospital Association, the American Association of
Homes and Services for the Aging, and the National Hospice and
Palliative Care Organization.
Speaking to the facility's staff, a member of the award committee
said. "You obviously want to help people live as fully as possible, but
you've somehow made peace with the fact that they are eventually
going to die." In that remark, the speaker caught something of St.
Joseph's Manor's essential spirit.
-Karin "TeddT Tomsic
MARCH - APRIL 2002 • 2 5
PASTORAL
CARE
IN
THE
LTC
SETTING
have time for such conversations. Residents can
also call on the chaplain to help them work
through memories, issues, and relationships that
need healing. Residents who spend time with a
chaplain exploring their personal and spiritual histories, religious backgrounds, and family values
will find the results helpful in expressing their
goals. (Family members can provide such information for residents with cognitive loss.)
Having learned about a resident's history ,md
values, a chaplain can share this vital information
with the medical and nursing staff (always
respecting the resident's right to confidentiality,
of course). Thus informed, the care team will
have a more three-dimensional view of the resident and can more easily take his or her goals into
consideration.
" T H E HORSE ON THE TABLE"
It is during the time immediately before .md after
admission that residents and their family members
think most about the approach of death, although
few verbalize it. The situation is reminiscent of an
old story in which a man goes to a guru to ask
about the meaning of life and death. In reply, the
guru describes a dinner party. The guests at this
partv are led into a room containing a long table.
On the table is a horse. The guests, hoping to spare
the host from embarrassment, say nothing about
the animal. The host, also shocked at the sight, is
silent as well. The guests, uncomfortable at the
sight, burn- through the meal and leave the party.
Later, when they happen to meet, they are unable
to recall the joy they once took in one another's
company. All they can remember is the discomfort
thev experienced in the presence of the horse.
So it often is with residents and their families at
admission. One cause of the negative thinking
surrounding long-term care is our society's denial
of the fact of death. When .\n aged person is
admitted to a nursing home, everyone involved
senses that the new resident's life is becoming
more fragile and that death is approaching. For
this reason, a LTC facility should ascertain the resident's wishes concerning end-of-life care at the
time he or she is admitted—because doing so is a
way of acknowledging the "horse on the table."
Increasingly these days, residents arrive with
their advance directives already signed, a phenomenon that indicates a growing public awareness of the need to be prepared for the end of
life. Chaplains can be called upon to assist those
new residents who do not have advance directives however. Indeed, simply being introduced
to a chaplain often induces a new resident to talk
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MARCH - APRIL 2 0 0 2
about his or her values concerning end o f life
care. Sometimes family members are shocked to
hear the issue raised. Rut the residents them
selves usually respond directly and with grace,
which indicates that they have already given the
matter a good deal of thought.
As the horse story suggests, once a forbidden
subject has finally been raised, people feel much
more free to talk openly. In LTC facilities, once
death has been mentioned, both residents and
their loved ones are freer to share their hopes,
express the love they feel, and admit the pain they
anticipate at being separated.
PASTORAL CARE AND RESIDENTS
Speaking of our pastoral care staff, Judith Ryan,
the director of admissions, recently said:
When you conduct a resident admission
interview, you speak very clearly about our
mission and philosophy of care. You seem
more comfortable getting into the "sticky
stuff" concerning resuscitation, do-notrcsuscitate orders, and our palliative care and
comfort care protocols. You answer questions about our policies and explain what the
resident and his or her family can expect if
the physician should order one of these
approaches. Your ease in discussing this
enables all of us to feel more comfortable.
Both resident and family members gain a
clearer picture of the religious [values] component of care. And that, I think, is why
many of our residents choose to come here.
Ryan went on to say that admissions personnel
often find that potential residents and their families
respond positively when they learn that St. Joseph's
Manor has a pastoral care department. "They seem
to become much more comfortable. Learning that
we have pastoral care appears to alleviate a lot of the
guilt and gives them a chance to express their spirituality, and that makes a huge difference."
A resident's spiritual needs and his or her
desire to be a part of religious scrv ices are important—but often undervalued—aspects of care in
any LTC facility. Many of our residents decide to
come here because it is a Catholic facility, a place
where thev can celebrate dailv Mass in the pres
encc of the sacraments. Concerning the facility's
pastoral care program, Ellen O'Brien, our former
recreation director, once said:
Each year, I have the opportunity to attend
a meeting of the presidents of Resident
HEALTH PROGRESS
Councils from across the state. The
[Connecticut] Department on Aging sponsors this meeting. One of the top three hot
topics discussed is the lack of spiritual and
religious support that many facilities report.
I have heard such comments as "Catholic
mass is held once a month" and "No one
comes to visit unless you belong to the local
church in that community." [ In this state], it
is the responsibility of the Recreation
Department to provide religious and spiritual support under the public health code. . . .
I cannot begin to express the value of having
a Pastoral (are Department.
PASTORAL CARE AND ADMINISTRATION
"Residents come here for our spiritual care as
much as for our nursing care," agreed Sr. Michelle
Anne Reho, O . C a r m . , Sr. Joseph's M a n o r ' s
administrator. Some LTC administrators hesitate
to spend money on pastoral care because they see
it as a "luxury." In Sr. Reno's opinion, however,
spiritual care is an integral part of health care. She
recently described the launching of our pastoral
care program in 1986. "Once we had determined
that our residents' spiritual needs were being met,
we looked at the money we had available and then
we looked for someone who would agree to work
for that amount," she said. "As the department
grew, we borrowed resources from other depart
ments. Let's face it: Pastoral care is not our most
expensive department. For what we pay one
n u r s e , we could almost hire two chaplains.
Unfortunately, that's how the salaries arc."
Sr. Reho explained the salary problem. "In
Connecticut," she said, "the only fully reimbursable positions are nursing positions. Pastoral
care—like recreation, social work, dietary, house
keeping, and laundry services—is described as an
'indirect service.'" The cost of pastoral care, like
that of those other services, must thus be partly
borne by the facility itself. "But we would no
more try to do without pastoral services than we
would do without dietary or laundry services."
The facility's Pastoral Care Department provides a variety of services. "For example, the
chaplains bring up the 'comfort cart'* for family
members sitting vigil for a dying loved one," Sr.
Reho said. "They make sure the kitchen understands that it must send up meals for family mem
hers. These may seem small things, but they are
St. Joseph's 'comfort cart' carries Bibles, other inspirational material, and toiletries for family members sitting
vigil.
HEALTH
PROGRESS
greatly appreciated by the families involved. They
are also appreciated by the nursing staff, who are
thus spared doing those chores themselves."
Of course, the department's primary duty is
providing spiritual care to residents and their
families. "The chaplains help residents, regardless
of their denominational background, to express
their values, reconcile their lives, and prepare for
death," Sr. Reho said. "They help families make
decisions in the dying resident's best interests,
get ready for separation, and enjoy the precious
rime left at the end of life."
Should the leaders of an LTC facility that does
not have ,i pastoral care program establish one? "I
would advise them to do it," Sr. Reho said. "A facilitv without a program should hire a certified chaplain
and get started. It will soon see the benefits." o
N O T E S
1. Joanne Lynn. "Learning to Care for People With Chronic Illness Facing the End of Life." JAMA. November
2000. pp. 2.508-2.511.
2. Michele Le Doux S a k u r a i . " C e r t i f i c a t i o n : Professionalism in Chaplaincy." Vision, May 2 0 0 1 . pp. 9-11.
The description of the NACC certification process
comes from this article.
3. See Karin "Teddi" Tomsic. "Pastoral Care in a LongTerm Care Setting," Health Progress, May-June 1998.
pp. 42-44. The article is one of seven in a special section entitled "Pastoral Care across the Continuum."
PASTORAL SUPPORT SURVEY
Sixty-five St. Joseph's Manor residents, family members of residents,
and staff members responded to a recent survey concerning pastoral
care at the facility. The survey questions were:
• Do residents benefit from the presence of the pastoral care staff?
(Thirty-six respondents said "Most often"; 11 said "Often"; 17 said
"Sometimes"; and none said either "Rarely" or "Not at all.")
• Do family members benefit? (Twenty-five said "Most often"; 18 said
"Often"; 16 said "Sometimes"; no one said "Rarely"; and 4 said "Not at
all.")
• Does the staff benefit? (Eighteen said "Most often"; 10 said "Often";
22 said "Sometimes"; 5 said "Rarely"; and 7 said "Not at all.")
• Is your job easier because of the presence of pastoral care? (A dozen
said "Most often"; 8 said "Often"; 14 said "Sometimes"; 8 said
"Rarely"; and 10 said "Not at all.")
• Do you feel personally supported by pastoral care? (Twenty-nine said
"Most often"; 8 said "often"; 10 said "Sometimes"; 6 said "Rarely":
and 10 said "Not at all.")
MARCH - APRIL 2 0 0 2
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